ADMISSIONKey indicators include: number of community members served, health status improvements, wait times, readmission/ED visit rates, falls prevention, client satisfaction, community awareness, partnership engagement. Also track population-specific indicators like chronic disease management, imm
ASSESSMENTSystematic evaluation using validated tools. Completed within required timeframes and when status changes. Documentation supports care planning. Required for accreditation compliance.
ORIENTATIONTeam members participate in orientation prior to their first shift and receive continuing education on service delivery standards, client-centered care approaches, and best practices. Training includes mandatory modules, hands-on practice, competency validation, and annual refreshers. Educ
BELONGINGSBelongings in long-term care involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
CAREPLANCareplan in long-term care involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
MEDICATIONAll SJHCG clients will be positively identified by two identifiers prior to the administration of medication or delivery of services. Examples include the client's full name and date of birth.
PREFERENCESWe wanted to develop a diabetes management program. We held focus groups with clients to understand needs/preferences. They told us timing and transportation were barriers.
FAMILYFall risk is communicated through care plan documentation, visual cues (e. , color codes), huddles, and transfer of accountability reports. Changes in risk are communicated to the team and family immediately.
DOCUMENTINGMy role includes conducting comprehensive assessments, developing person-centered service plans, providing skilled care, coordinating with the healthcare team, monitoring progress, and documenting care provided.
TRANSITIONWe obtain consent for info sharing, communicate via secure methods, participate in care coordination meetings, and ensure smooth transitions by documenting all coordination activities. At SJHCG, care coordination uses Caseworks, Oscar Pro, and Care Dove platforms to share information with
